Kona Community Hospital

All Charges

Charge

Type

Setting

Price

METRONIDAZOLE 250 MG PO TABLET

Facility

$2.40

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.22
Max. Negotiated Rate	$2.33
Rate for Payer: Cash Price	$1.56
Rate for Payer: Hawaii Western Management Group Commercial	$2.28
Rate for Payer: Health Management Network Commercial	$2.04
Rate for Payer: Kaiser Permanente Commercial	$1.51
Rate for Payer: Kaiser Permanente Medicaid	$1.22
Rate for Payer: MDX Hawaii PPO	$2.33
Rate for Payer: UnitedHealthcare Medicaid	$1.44
Rate for Payer: University Health Alliance Commercial	$1.75

METRONIDAZOLE IN NACL (ISO-OS) 500 MG/100 ML IV IVPB

Facility

$11.60

Service Code	HCPCS J1836
Hospital Revenue Code	250
Min. Negotiated Rate	$9.86
Max. Negotiated Rate	$11.25
Rate for Payer: Cash Price	$7.54
Rate for Payer: Health Management Network Commercial	$9.86
Rate for Payer: MDX Hawaii PPO	$11.25

METRONIDAZOLE IN NACL (ISO-OS) 500 MG/100 ML IV IVPB

Facility

$11.60

Service Code	HCPCS J1836
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$11.25
Rate for Payer: Cash Price	$7.54
Rate for Payer: Cash Price	$7.54
Rate for Payer: Hawaii Medical Service Association ABD	$0.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.03
Rate for Payer: Hawaii Western Management Group Commercial	$11.02
Rate for Payer: Health Management Network Commercial	$9.86
Rate for Payer: Kaiser Permanente Commercial	$7.31
Rate for Payer: Kaiser Permanente Medicaid	$5.92
Rate for Payer: MDX Hawaii PPO	$11.25
Rate for Payer: UnitedHealthcare Medicaid	$6.96
Rate for Payer: University Health Alliance Commercial	$8.46

MICONAZOLE NITRATE 2 % TOP CR

Facility

$11.29

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$10.95
Rate for Payer: Cash Price	$7.34
Rate for Payer: Cash Price	$47.24
Rate for Payer: Hawaii Western Management Group Commercial	$10.73
Rate for Payer: Hawaii Western Management Group Commercial	$69.05
Rate for Payer: Health Management Network Commercial	$61.78
Rate for Payer: Health Management Network Commercial	$9.60
Rate for Payer: Kaiser Permanente Commercial	$7.11
Rate for Payer: Kaiser Permanente Commercial	$45.79
Rate for Payer: Kaiser Permanente Medicaid	$37.07
Rate for Payer: Kaiser Permanente Medicaid	$5.76
Rate for Payer: MDX Hawaii PPO	$70.50
Rate for Payer: MDX Hawaii PPO	$10.95
Rate for Payer: UnitedHealthcare Medicaid	$6.77
Rate for Payer: UnitedHealthcare Medicaid	$43.61
Rate for Payer: University Health Alliance Commercial	$52.98
Rate for Payer: University Health Alliance Commercial	$8.23

MICONAZOLE NITRATE 2 % TOP CR

Facility

$11.29

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$9.60
Max. Negotiated Rate	$10.95
Rate for Payer: Cash Price	$7.34
Rate for Payer: Cash Price	$47.24
Rate for Payer: Health Management Network Commercial	$61.78
Rate for Payer: Health Management Network Commercial	$9.60
Rate for Payer: MDX Hawaii PPO	$70.50
Rate for Payer: MDX Hawaii PPO	$10.95

MICONAZOLE NITRATE 2 % VAG CR

Facility

$32.79

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$16.72
Max. Negotiated Rate	$31.81
Rate for Payer: Cash Price	$21.31
Rate for Payer: Hawaii Western Management Group Commercial	$31.15
Rate for Payer: Health Management Network Commercial	$27.87
Rate for Payer: Kaiser Permanente Commercial	$20.66
Rate for Payer: Kaiser Permanente Medicaid	$16.72
Rate for Payer: MDX Hawaii PPO	$31.81
Rate for Payer: UnitedHealthcare Medicaid	$19.67
Rate for Payer: University Health Alliance Commercial	$23.90

MICONAZOLE NITRATE 2 % VAG CR

Facility

$32.79

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$27.87
Max. Negotiated Rate	$31.81
Rate for Payer: Cash Price	$21.31
Rate for Payer: Health Management Network Commercial	$27.87
Rate for Payer: MDX Hawaii PPO	$31.81

MICROFIBRIL. COLLAGEN HEMOSTAT 2 X 6.25 X 7 CM-CM-MM TOP SPONGE

Facility

$204.30

Service Code	NDC 53276105002
Hospital Revenue Code	250
Min. Negotiated Rate	$173.66
Max. Negotiated Rate	$198.17
Rate for Payer: Cash Price	$132.80
Rate for Payer: Health Management Network Commercial	$173.66
Rate for Payer: MDX Hawaii PPO	$198.17

MICROFIBRIL. COLLAGEN HEMOSTAT 2 X 6.25 X 7 CM-CM-MM TOP SPONGE

Facility

$204.30

Service Code	NDC 53276105002
Hospital Revenue Code	250
Min. Negotiated Rate	$104.19
Max. Negotiated Rate	$198.17
Rate for Payer: Cash Price	$132.80
Rate for Payer: Hawaii Western Management Group Commercial	$194.09
Rate for Payer: Health Management Network Commercial	$173.66
Rate for Payer: Kaiser Permanente Commercial	$128.71
Rate for Payer: Kaiser Permanente Medicaid	$104.19
Rate for Payer: MDX Hawaii PPO	$198.17
Rate for Payer: UnitedHealthcare Medicaid	$122.58
Rate for Payer: University Health Alliance Commercial	$148.91

MICROFIBRIL. COLLAGEN HEMOSTAT 8 X 12.5 X 1 CM TOP SPONGE

Facility

$376.08

Service Code	NDC 53276105004
Hospital Revenue Code	250
Min. Negotiated Rate	$319.67
Max. Negotiated Rate	$364.80
Rate for Payer: Cash Price	$244.45
Rate for Payer: Health Management Network Commercial	$319.67
Rate for Payer: MDX Hawaii PPO	$364.80

MICROFIBRIL. COLLAGEN HEMOSTAT 8 X 12.5 X 1 CM TOP SPONGE

Facility

$376.08

Service Code	NDC 53276105004
Hospital Revenue Code	250
Min. Negotiated Rate	$191.80
Max. Negotiated Rate	$364.80
Rate for Payer: Cash Price	$244.45
Rate for Payer: Hawaii Western Management Group Commercial	$357.28
Rate for Payer: Health Management Network Commercial	$319.67
Rate for Payer: Kaiser Permanente Commercial	$236.93
Rate for Payer: Kaiser Permanente Medicaid	$191.80
Rate for Payer: MDX Hawaii PPO	$364.80
Rate for Payer: UnitedHealthcare Medicaid	$225.65
Rate for Payer: University Health Alliance Commercial	$274.12

Micropuncture Tranitionless Access Set G43872 [3643812]

Facility

$313.05

Service Code	HCPCS C1769
Hospital Charge Code	3643812
Hospital Revenue Code	272
Min. Negotiated Rate	$266.09
Max. Negotiated Rate	$303.66
Rate for Payer: Cash Price	$203.48
Rate for Payer: Health Management Network Commercial	$266.09
Rate for Payer: MDX Hawaii PPO	$303.66

Micropuncture Tranitionless Access Set G43872 [3643812]

Facility

$313.05

Service Code	HCPCS C1769
Hospital Charge Code	3643812
Hospital Revenue Code	272
Min. Negotiated Rate	$159.66
Max. Negotiated Rate	$303.66
Rate for Payer: Cash Price	$203.48
Rate for Payer: Hawaii Western Management Group Commercial	$297.40
Rate for Payer: Health Management Network Commercial	$266.09
Rate for Payer: Kaiser Permanente Commercial	$197.22
Rate for Payer: Kaiser Permanente Medicaid	$159.66
Rate for Payer: MDX Hawaii PPO	$303.66
Rate for Payer: University Health Alliance Commercial	$228.18

Midas Rex 10-Ast Dissecting Tool 10ov40 [3643378]

Facility

$1,342.59

Hospital Charge Code	3643378
Hospital Revenue Code	272
Min. Negotiated Rate	$684.72
Max. Negotiated Rate	$1,302.31
Rate for Payer: Cash Price	$872.68
Rate for Payer: Hawaii Western Management Group Commercial	$1,275.46
Rate for Payer: Health Management Network Commercial	$1,141.20
Rate for Payer: Kaiser Permanente Commercial	$845.83
Rate for Payer: Kaiser Permanente Medicaid	$684.72
Rate for Payer: MDX Hawaii PPO	$1,302.31
Rate for Payer: University Health Alliance Commercial	$978.61

Midas Rex 10-Ast Dissecting Tool 10ov40 [3643378]

Facility

$1,342.59

Hospital Charge Code	3643378
Hospital Revenue Code	272
Min. Negotiated Rate	$1,141.20
Max. Negotiated Rate	$1,302.31
Rate for Payer: Cash Price	$872.68
Rate for Payer: Health Management Network Commercial	$1,141.20
Rate for Payer: MDX Hawaii PPO	$1,302.31

Midas Rex 14-AM Dissecting Tool 14BA60 [3642286]

Facility

$1,267.62

Hospital Charge Code	3642286
Hospital Revenue Code	272
Min. Negotiated Rate	$646.49
Max. Negotiated Rate	$1,229.59
Rate for Payer: Cash Price	$823.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,204.24
Rate for Payer: Health Management Network Commercial	$1,077.48
Rate for Payer: Kaiser Permanente Commercial	$798.60
Rate for Payer: Kaiser Permanente Medicaid	$646.49
Rate for Payer: MDX Hawaii PPO	$1,229.59
Rate for Payer: University Health Alliance Commercial	$923.97

Midas Rex 14-AM Dissecting Tool 14BA60 [3642286]

Facility

$1,267.62

Hospital Charge Code	3642286
Hospital Revenue Code	272
Min. Negotiated Rate	$1,077.48
Max. Negotiated Rate	$1,229.59
Rate for Payer: Cash Price	$823.95
Rate for Payer: Health Management Network Commercial	$1,077.48
Rate for Payer: MDX Hawaii PPO	$1,229.59

Midas Rex 14-AM Dissecting Tool 14TA30 [3642290]

Facility

$1,455.04

Hospital Charge Code	3642290
Hospital Revenue Code	272
Min. Negotiated Rate	$742.07
Max. Negotiated Rate	$1,411.39
Rate for Payer: Cash Price	$945.78
Rate for Payer: Hawaii Western Management Group Commercial	$1,382.29
Rate for Payer: Health Management Network Commercial	$1,236.78
Rate for Payer: Kaiser Permanente Commercial	$916.68
Rate for Payer: Kaiser Permanente Medicaid	$742.07
Rate for Payer: MDX Hawaii PPO	$1,411.39
Rate for Payer: University Health Alliance Commercial	$1,060.58

Midas Rex 14-AM Dissecting Tool 14TA30 [3642290]

Facility

$1,455.04

Hospital Charge Code	3642290
Hospital Revenue Code	272
Min. Negotiated Rate	$1,236.78
Max. Negotiated Rate	$1,411.39
Rate for Payer: Cash Price	$945.78
Rate for Payer: Health Management Network Commercial	$1,236.78
Rate for Payer: MDX Hawaii PPO	$1,411.39

Midas Rex 15-A Dissecting Tool 15BA40 [3642287]

Facility

$931.88

Hospital Charge Code	3642287
Hospital Revenue Code	272
Min. Negotiated Rate	$475.26
Max. Negotiated Rate	$903.92
Rate for Payer: Cash Price	$605.72
Rate for Payer: Hawaii Western Management Group Commercial	$885.29
Rate for Payer: Health Management Network Commercial	$792.10
Rate for Payer: Kaiser Permanente Commercial	$587.08
Rate for Payer: Kaiser Permanente Medicaid	$475.26
Rate for Payer: MDX Hawaii PPO	$903.92
Rate for Payer: University Health Alliance Commercial	$679.25

Midas Rex 15-A Dissecting Tool 15BA40 [3642287]

Facility

$931.88

Hospital Charge Code	3642287
Hospital Revenue Code	272
Min. Negotiated Rate	$792.10
Max. Negotiated Rate	$903.92
Rate for Payer: Cash Price	$605.72
Rate for Payer: Health Management Network Commercial	$792.10
Rate for Payer: MDX Hawaii PPO	$903.92

Midas Rex 15-A Dissecting Tool 15TA23 [3642285]

Facility

$1,422.91

Hospital Charge Code	3642285
Hospital Revenue Code	272
Min. Negotiated Rate	$725.68
Max. Negotiated Rate	$1,380.22
Rate for Payer: Cash Price	$924.89
Rate for Payer: Hawaii Western Management Group Commercial	$1,351.76
Rate for Payer: Health Management Network Commercial	$1,209.47
Rate for Payer: Kaiser Permanente Commercial	$896.43
Rate for Payer: Kaiser Permanente Medicaid	$725.68
Rate for Payer: MDX Hawaii PPO	$1,380.22
Rate for Payer: University Health Alliance Commercial	$1,037.16

Midas Rex 15-A Dissecting Tool 15TA23 [3642285]

Facility

$1,422.91

Hospital Charge Code	3642285
Hospital Revenue Code	272
Min. Negotiated Rate	$1,209.47
Max. Negotiated Rate	$1,380.22
Rate for Payer: Cash Price	$924.89
Rate for Payer: Health Management Network Commercial	$1,209.47
Rate for Payer: MDX Hawaii PPO	$1,380.22

Midas Rex MC Dissecting Tool MC254 [3642288]

Facility

$1,594.25

Hospital Charge Code	3642288
Hospital Revenue Code	272
Min. Negotiated Rate	$813.07
Max. Negotiated Rate	$1,546.42
Rate for Payer: Cash Price	$1,036.26
Rate for Payer: Hawaii Western Management Group Commercial	$1,514.54
Rate for Payer: Health Management Network Commercial	$1,355.11
Rate for Payer: Kaiser Permanente Commercial	$1,004.38
Rate for Payer: Kaiser Permanente Medicaid	$813.07
Rate for Payer: MDX Hawaii PPO	$1,546.42
Rate for Payer: University Health Alliance Commercial	$1,162.05

Midas Rex MC Dissecting Tool MC254 [3642288]

Facility

$1,594.25

Hospital Charge Code	3642288
Hospital Revenue Code	272
Min. Negotiated Rate	$1,355.11
Max. Negotiated Rate	$1,546.42
Rate for Payer: Cash Price	$1,036.26
Rate for Payer: Health Management Network Commercial	$1,355.11
Rate for Payer: MDX Hawaii PPO	$1,546.42

Know your out-of-pocket cost for care.

All Charges